Public Bill Committee

[Mr. Edward O'Hara in the Chair]
H 09 British Retail Consortium

Edward O'Hara: Welcome back, members of the Committee, fit and ready for purpose.

Clause 8

Quality accounts

Michael Penning: I beg to move amendment 87, in clause 8, page 5, line 6, after containing, insert (but not limited to).

Edward O'Hara: With this it will be convenient to discuss the following: amendment 156, in clause 8, page 5, line 27, after containing, insert (but not limited to).
Amendment 169, in clause 8, page 5, line 28, at end insert
(3A) When required, bodies listed in subsection (2) must provide information for injury data collection on the causes of injuries for patients admitted..

Michael Penning: Thank you, Mr. OHara. It is a pleasure to discuss this part of the Bill. I am pleased that the amendments have been grouped together. We are minded, like a lot of stakeholders, to support quality accounts. The amendments are probing amendments to find out from the Government exactly what the quality accounts will look like. Sadly, a lot of the detail is likely to be covered in secondary legislation.
Stakeholders, such as the NHS Confederation, the Kings Fund, Help the Aged and others are concerned about the lack of detail. In fact, the Kings Fund believes that the publication will be relatively passive in its form and will not give the public the accountability of quality that we are looking for. Looking back to the Maidstone debacle and the shameful events that took place in Mid Staffordshire NHS Foundation Trust, the quality of the accounts that the public can see is important, as I am sure the Minister agrees. Amendments 87 and 156 would develop exactly who will be responsible for publishing quality accounts. The phrase not limited to is self-explanatory about where we are coming from.
I support Liberal Democrat amendment 169. It is important that data that could be used in other areas of public analysis are available. In recent years, we have not seen data on injuries within hospitals. For example, it is difficult for us, when tabling parliamentary questions, to find out from trusts the exact type of injuries dealt with by A and E departments. It is imperative that such information is available. I have tabled the amendment to urge the Minister to develop exactly who quality accounts will be limited to.

Sandra Gidley: We, too, welcome the general idea of quality accounts but, to be useful, we must ensure that the information has a purpose and is not just another data collection exercise with no meaningful use. The accounts will have more credibility if the public can see that the information is put to good use. I welcome the Conservative amendments. They would widen the scope of quality accounts and make them more flexible in the future.
I want to discuss amendment 169. Before being approached by the Royal Society for the Prevention of Accidents, I had not realised that the United Kingdom used to be a world leader in injury surveillance. It had much useful data on how many people were hurt in accidents, what they were doing at the time and what products might have been involved. The data were used to analyse trends. Obviously if one is analysing trends, one should then take steps to ensure that there are no such accidents in the future.
Until 2002 the Department of Trade and Industry collected that data, but when the Department was reformed as the Department for Business, Enterprise and Regulatory Reformthere has obviously been another reorganisation since thenthe data were no longer collected. The amendment is a probing amendment to see whether there is any facility to use the quality accounts, which might be collecting some of that data anyway, to reinstate injury data collection, so that once again the UK can be at the forefront of data collection, analysis and the prevention of accidents.

Mike O'Brien: Essentially, what we have here is the collection of information and its publication for a particular purpose. That purpose is not only to inform people but to ensure a focus on quality. That arises out of the review by my noble Friend Lord Darzi into high quality care for all. He determined that quality relates to three domainspatient safety, effectiveness of care, and patient experience. I wish to set out what we mean by that and say something more generally about the quality accounts, so that hopefully people have a clear picture of our purpose and of why we are focusing on quality, and understand therefore why we cannot accept the amendments. I appreciate and am grateful for the indication from the official Opposition both that they support the concept of quality accounts and that the amendments are probing ones, designed to elicit more information about the nature of quality accounts.
We want to develop quality accounts to see whether the focus in the High Quality Care for All review is being used by organisations in the health service. That means that they are, for example, protecting patient safety by eradicating health care-acquired infections and avoidable accidents. It is about the effectiveness of care, from the clinical procedure that the patient receives to their quality of life after treatment, and it is about the patients entire experience of the NHS, ensuring that they are treated with compassion, dignity and respect in a clean, safe and well-managed environment.
Those are the three key areas that we want to focus on, and we intend quality accounts to contain a core of nationally determined quality indicators, so that comparisons can be made between providers. It is important that like can be compared with like, in respect of that core. The greater part of each quality account, however, will be determined locally, to ensure that providers can publish information that is relevant to the type of health care services that they provide, to the locally identified priorities for clinical improvement and to patients and other members of the public in their area.

Michael Penning: The key here is public confidence in the data that are being published. While I am a localist politician, I am concerned about public confidence, because if there are problems in a trustwe all know that that happens; the Mid Staffordshire trust was a great examplein the main, as the Minister has just indicated, it is up to the trust to decide who publishes what information about what.

Mike O'Brien: One key thing we need to do is ensure that data that are published are not just left out there, unverified. It will be the responsibility of the Care Quality Commission to ensure that the data are looked at and conform to the data that it has about that hospital. If there are problems with the data in a report, correction within 21 days can be required. The hon. Gentleman is right. If we are to focus on quality, we need to assure the publicas far as we can ever rely on the expression of an opinion by an organisationthat it is as reliable as it reasonably can be. We are concerned that it should not focus just on the things that we have focused on in the past such as particular targets 18 weeks and others. This is looking at something differentthe quality, not the quantity, of the care that is provided. We also want to ensure that a quality account, which will be locally determined, puts quality care at the forefront. By high quality care, we mean care that is beyond the minimum set by the regulator.
This is not just about saying a particular target has been hit. In order to manage the NHS and get a return on the money going into it, we have sought to set basic standards with which everyone has to comply. We are now, with quality accounts, looking at something quite different. This is not about hitting minimum standards, although that will still be relevant, because if people are not doing so it will come out in other reports such as those by the CQC. We are now asking hospitals and other NHS institutions to look at what they do well. That involves two things: identifying who is performing at a very high quality level in particular areas and then comparing the best in different areas. It is not about minimums: it is about the best and how to keep the pressure on to push the best to be better; it is about making the reasonably good, good; and it is about making the good even better and excellent. It is also about testing those who are excellent to see whether they can push themselves further. They will have to say not only what they are good at but also what further improvements over time they want to see. We know that the medical teams that forge ahead and provide quality and excellence in the NHS are those that measure their performance, and the best are often well above minimum standards. They measure how well they are doing for their own purposes, but until now nobody has taken particular notice, because people think, They are above the minimum. We need not worry. But how do we make everyone perform to the highest level that they can? Quality accounts are part of that process.

Andrew Turner: I welcome the purpose of getting the maximum possible, but I am concerned about the minimum. I am concerned, for example, about elderly people who are in hospitals, who have nowhere to go, who cannot go home because they cannot look after themselves and who are not sent to less significant units. This happens right across the country, not just in my constituency. In most parts of the country there is something wrong every so oftennot frequently, not all the time, but regularly. That fact is neglected, and I would like to hear more about how the minimum is achieved, before we get to the maximum.

Mike O'Brien: I understand the hon. Gentlemans point and he is right that the minimum is important. As the hon. Member for Hemel Hempstead has indicated, we saw the outcome of events at Mid Staffordshire NHS Foundation Trust, where various tests on the trust did not pick up the poor quality of treatment. Therefore, we need to ensure that we examine the minimum standards as well. An organisation that looks at minimum standards of care blew the whistle on what was happening at Mid Staffordshire. We have checks in place through the Care Quality Commission and, if the organisation in question is a foundation trust, through Monitor, to some extent. Such bodies need to ensure that the quality of basic standards is examined. The NHS Choices database is available to the public, who can look in detail at how hospitals and other NHS institutions are performing and at the quality of different teams to ensure that they are doing what they are obliged to do. Checks are there, and the minimum standards will be dealt by the CQC with its new enforcement powers, which start in April 2010 for acute trusts. A core CQC registration will form part of the quality accounts, so there are ways of doing it.
My point is that, as important as it is to ensure that minimum standards are hit and maintained, it is also important to go beyond that and recognise that the NHS is not about minimum standards. Wemillions of us throughout the countrydo not pay taxes for the NHS to get the minimum possible standards in a hospital; we expect those standards. We want hospitals that push to get the best and the highest quality, and where excellence is important. Across the NHS, there are people, medical teams and practitioners who are dedicated to excellence and who, until now, have not been measured and congratulated. Doing that will show that the NHS cares about excellence. The NHS talks a lot about excellence but does not measure it, which is what quality accounts are about.
The local part of those quality accounts enables local involvement networks to let the hospital or other institution know what they want the quality accounts to measure, providing it is about quality. That is what we want to focus on, and it is the agenda that we are pursuing. Providers will have the freedom and the responsibility to decide what goes into the local part of quality accounts. However, we need to stipulate that quality accounts are about quality, which is why clause 8 refers specifically to
information relevant to the quality of...NHS services.
For that reason, amendments 87 and 156 are not the way that we want to go.
Similarly, I understand the concerns raised by the hon. Member for Romsey, who is not in her place. I agree entirely that there needs to be a robust collection of data on the type of injuries that cause people to be admitted to hospital in the first place. However, such information is not within the scope of the quality account, because that information is, in effect, about quantity, and it measures something else. The information in the quality account must be relevant to the quality of a particular providers care. Data on the causes of admission, such as personal injuries, are available through other means. Information on accident and emergency attendance, for example, is collected as part of the hospital episodes statistics database, and it is already available on the information centres website.
Statistics show that there is a remarkable appetite for information about health issues. Figures for the NHS Choices website show that around 5 million people visit that site each month, with total visits occasionally reaching around 7 million a month. Given the number of people in this country, those figures are extraordinary, and I think that, when quality accounts are made available, we will see the publics appetite to see the quality of provision available in their local hospital.

Andrew Turner: How many areas will be visited each year, and how many of those will be top rank? It would be helpful if we had some idea of what the Minister expects for this year or next. Also, how many of those visits will involve the whole of an NHS trust, and how many of them will involve operations, some of which may be less good, within an NHS trust?

Mike O'Brien: We have an idea of the quality of some trusts through knowing about those that are hitting basic standards and through reports published in relation to inspections by CQC and its predecessor bodies, so we have some ability to assess the quality by which a trust performs its services. Information on individual medical teams and the extent to which components of trusts, which is what the hon. Gentleman has asked about, are performing to the highest standards, is less available, although there are some data in relation to that on the NHS Choices website.
I have no doubt that within the medical profession, a consultant knows whether another consultant at a hospital down the road is better and who is the best at a particular speciality in the country. Such information is available in the medical press, no doubt, but we want to provide accessible information to the public, so that they can see a relatively brief report reasonably easily. We have made it clear that we do not want lengthy, unreadable documents, because they are intended for members of the public, who will be able to see the quality delivered by, and the performance of, their local NHS organisation. More than that, we want the public to see the improvements that an organisation wants to make to the way in which it delivers quality during the coming year and in the future.
There will be a fair amount of freedom for the various organisations to say what they want to look at or whether they have a particular specialism. There might be a specialist team in orthopaedics, and it will be able to say, We have got a medical team that is able to do something like this. It is not being done anywhere else in the country, we are at the forefront. Such organisations will be able to advertise the areas in which they are the best, but they will also have to indicate areas where they are mediocre and state what they plan to do about it. An organisation might be above the minimum standard and pass tests by delivering what it needs to deliver, but it still might not match the best. It must say how it will improve over the coming years and what it is delivering in terms of patient quality. Patient quality is not a general concept; it has been set out my noble Friend Lord Darzi in his report, and we want to focus on it as something that the NHS will seek to deliver over the coming decade or more.
I will tell the story going back over the past 10 years. At the start of the decade, we recognised that there was a problem of underfunding and understaffing in the NHSwe had recognised that before, but we always had expenditure constraints. At that point, we started to put funding in, and we used the basic tool of targets in order to see what return we were getting. In the second tranche of change, we recognised that we had to go beyond merely putting in more money and setting targets for delivery and that there needed to be fundamental reforms in the NHS organisation.
Therefore, we went through a period of NHS reform. It was very painful and involved reconfiguration, the reorganisation of some NHS structures and trying out different ways of doing that until we felt that we had reached a system that could enable the delivery of better quality administration in the NHS. We think that we have broadly arrived at that, and we do not plan significant further administrative changes.
We now need to move to the next stage, which is where quality accounts will take us. The review by my noble Friend Lord Darzi focused on the issue of improved quality, so we have gone through a period of dealing with underfunding, understaffing and the necessary administrative changes, and we are now moving on to look at improving the quality of what the NHS does. It is a step-by-step improvement and in due course, as we fulfil the quality agenda, I hope that we will see an improvement in the quality of what we, as taxpayers and patients, get from the NHS.
Therefore, the issue of core accounts is at the centre of that vision for the future of the NHS and the next stage in improving it. I appreciate that the Opposition amendments are primarily probing amendments, and I hope that we will be able to acknowledge the importance of quality accounts and understand what they propose to do. I therefore hope that Opposition Members will not press their amendments.

John Horam: May I probe the Minister a little further on how he will organise this? I understand that the thinking might not have got down to this level yet, but as I understand it, he is trying to elevate quality accounts to the same level as financial accounts. There would be financial accounts and equality accounts at an equal level, just as many organisations have elevated environmental accounts to the same level as financial accounts, and report on them in the same way.
In the case of financial accounts, there is a clear historic structure. There is a finance director to whom people report, and there is a clear, understandable procedure that is followed every year and is understood by everybody. In this case, we are in relatively untrodden territory, as the Minister has admitted to some extent. We are even dealing with questions that are not simply about target setting, check lists and waiting times, but that concern rather more intangible things such as the nature of care and the compassion that is shown, which are much more difficult to measure. Who will be responsible for that in any organisation, whether it is a primary care trust or hospital trust? Will that responsibility be put specifically on the clinical directors shoulders, or will it lie with the operations director or the chief executive? In my experience, organisations and institutions do not work well unless there are specific, clear responsibilities. Obviously, quality goes right across the board. Everyone is concerned about quality in a hospital or primary care trust, but, none the less, someone will be collecting the information and pushing the agenda along. Has there been any thinking on that?

Mike O'Brien: I agree with the key thrust of the hon. Gentlemans points. We do not aim to create a new bureaucracy or a pile of information that needs to be collected to ensure that we can provide quality accounts. Much of the data that will be in quality accounts are available now. Currently, trusts provide the CQC with data about what they are doing, so that the CQC can look at the overall quality of what they are doing and can do its regular reports.
So, the data are provided to the CQC, rather than the public, and the CQC will periodically do a report based on some of those data. We want to make sure that those data are more readily accessible and available, as far as the core national data on quality are concerned, in a readable form for the public. Then, local NHS organisations will have particular data available to them, which they can measure themselves and can choose to put out there too. We hope that will lead to a focus on what they want to specialise in and where they can make a particular contribution to the NHS.
The hon. Gentleman asked who will be responsible, and that will vary through the NHS. In a hospital, the trust board will be responsible for the data that are out there. If they are medical data, the board will want to, and will be obliged to, consult the clinical director to make sure that the quality of those data are appropriate. In the end, the buck will stop with the board and with those who are legally responsible for the information that the trust puts out. That information will not just be out there unchecked. The CQC, which has much of that information anyway, will be able to say that some of it is not accurate. With local data, the CQC may say, Lets have a look at these data, because we want to find out the basis on which you have claimed that youre producing at this level of quality. If it found that the quality levels and the data backing them up were not sound enough, the trust or other organisation could be required to change them.

John Horam: So, it will be up to the trust in question to decide which member of staff is responsible for collecting and monitoring that information and presenting it to the board. I agree that the board is ultimately responsible, but there must be someone inside the organisation, below the board, who collates all the information and presents it to the board, just as a finance director collects all the accounts and presents them to the board.

Mike O'Brien: Clinical data are currently collected in any event, and I do not envisage that someone will get a new job on quality accounts. There will already be people who provide that information, and it will probably vary between the trusts who they decide should be responsible for delivering the text of a quality account. I am less concerned about that, and more concerned that, however they do it, we need to have quality accounts that the public can read and understand, and that are not too cumbersome or indigestible. They should be reliable and verifiable by outside organisations and they should give a clear picture of the quality of what is being delivered.
In the end, the people on the trust board, in the case of a hospital, for example, will be responsible. They will have procedures for making particular individuals responsible for particular aspects of the quality account. That will be a decision for themwe are not trying to top-down manage this. They will appoint clinical directors, there are good governance procedures which trusts are well aware ofsome more than others. The governance procedures are out there and they are well known. So there will be ways in which the data will be collected and the appropriate people will be held responsible.

Michael Penning: I want to clarify a couple of points before the Minister comes to his conclusion. The Government already have powers under section 8 of the National Health Service Act 2006 to ask NHS bodies for quality accounts. As they already have such powers, will this legislation bring in other bodies, perhaps those supplying services to the NHS? If there are already powers, I cannot understand why we need the clause, unless we are bringing in other bodies.
If we are asking the public, understandably, to have confidence in the accounts, the accounts must be like for like. Two trusts next to each other must be offering similar things, and we must have a level playing field. We do not want a postcode lottery.
So who will audit the accounts? The British Medical Association is concerned about that, and I share its concerns. As this is prescribed information on the quality of the services, the manner in which they are published should, as I just said, be equalin other words, there should be a level playing field. Who will audit the accounts, or will there not be an audit at all? If there is no form of audit, what is the logic of introducing the measure?

Mike O'Brien: On bringing in other bodies, the hon. Gentleman is right. Quality accounts will apply not just to hospitals. They will apply to other NHS organisations and providers of NHS services. Even those in the private sector who provide NHS services will be required to look at the quality of what they do and report on it, and that information should be available to the public so that taxpayers are able to see the quality of what they get.
It is important that the quality accounts are verifiable. I have already indicated that CQC will be able to examine and check them. There will not be an outside auditor such as Ernst and Young brought in. That is not the approach that we are taking. We are saying that the trust or other organisation board, the partners in a practice and so on will be responsible for writing a basic quality account. There will be core national things that they must include and other things that they may choose to include. They will be responsible for ensuring the quality of the quality account. There will be a failsafea checkto ensure that what they have done is not in any way unsound. The CQC will be there to do that, but I suspect that once these things are made public, others who work in the NHS will start looking at them and asking questions about them. If people are making claims that cannot be substantiated, I suspect that they will be caught out fairly quickly.

Michael Penning: As I said at the outset, we are broadly in support, but there is very little detail in the Bill. I hope that the Minister will understand why we have introduced these probing amendments and discussions. With that in mind, I do not wish to press amendments 87 and 156.

John Pugh: I want to make a few comments on amendment 169. I believe the Minister alluded to the fact that, in the past, targets have been slightly distorting, and that assessing quality from time to time can become distorting. I wonder to what extent assessment by the public of quality accounts will differ from internal assessment by professionals. In the case of education assessments and establishments, people inside the education world and the general public often have different readings of information that is made public. However, I accept that assessing quality, albeit at a subtle distance, may at the end of the day improve the quality of services.
The Minister mentioned that the clause draws a distinction between quantity and quality. The amendment is about quantity, while the particular clause is about quality, though I accept that quantity and statistics are often a good indication of the quality of a service being delivered. The amendment makes an important point about the necessity of collecting injury statistics and presenting them in ways that would lead people to consider what the causes and the preventions are of such injuries. I want to put on the record that my hon. Friend the Member for Romsey has gone to the Health Committee and has not abnegated her duties here.

Michael Penning: I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Michael Penning: I beg to move amendment 159, in clause 8, page 5, line 24, leave out paragraph (c).
The amendment would leave out the paragraph that stipulates that anyone who
makes arrangements...for another person to provide NHS services
those who are pursuing a contract or making an arrangement
for another person to provide or assist in providing
such serviceswill need to publish a document. Even though the noble Lord Darzi attempted to address the situation in the other place, there is still a lack of clarity in the Bill regarding which organisations that supplies services to the NHS will be required to provide. A few moments ago, the Minister listed some. It would be useful, at least in correspondence, if the Minister could indicate exactly which bodies that supply services to the NHS will be required. That is important, as so much of the detail required will be left to the Minister or the Secretary of State to decide under secondary legislation.
The concern is that not everyone is going to be caught up in the quality accounts. The consultation that took place regarding which bodies should be there wasI am sorry to sayslightly flawed. Out of the whole of the NHS, only 299 people responded, of which 11 were GPs. That is not a real barometer on the field of the wonderful service the NHS provides to the nation. Further consultation took place between the Department, the donation trusts and other NHS organisations. Some 15 NHS trusts respondednot a huge amountso did nine primary care trusts, one strategic health authority and the Foundation Trust Network. That is not a definitive list of respondents as to who will be caught up in the legislation.
The other thing, which I alluded to earlier, is the role of the CQC. The Minister responded that it will be the CQCs responsibility to look at the accounts. When and how often are the obvious questions. What is the role of Monitor in routinely examining information for presenting the quality accounts for the foundation trusts? That could lead to quite a punitive effect if we are not careful. The Governments assessments indicate that the accounts will be quite challenging for trusts. They may have to take on new and temporary staff. Exactly which organisations will be required to produce quality accounts must be definitive in the Bill, and it is disappointing that it is not.

Mike O'Brien: There is not, as such, a definitive list, because the NHS varies across the country and NHS services are provided in different ways. There is obviously a list of the organisations that we want to include, but because the operation of the NHS is so variable and because services are delivered in so many different ways, we essentially want to be able to say that if an NHS service is being provided, by either the public or private sector, and if patients receive a service, we want it to be qualitatively examined. We are not interested in the delivery of paper to a trust; we are interested in what the trust and medical teams are doing to deliver services to patients. The sub-contractors who will be covered include many services offered by independent sector treatment centres. That would mean that patients will be able to see the quality of what is done when services are provided to the NHS. If a private sector centre provides NHS services and private sector services, the latter are separate, so the centre will have to look after them. However, where facilities are used to deliver NHS services to NHS patients, we want quality accounts.

Michael Penning: I think everybody would understand if phase 1, 2 or 3if we get that farISTCs that were contracting had to do that, but what about other people that are contracting directly into the NHS such as dentists, the group of professionals about whom we were talking yesterday? They are self-employed and contracted to the PCT to deliver care from the primary sector directly to the public. Some practicesthere are not so many of them nowin rural parts of the country might consist of a single dentist with two dental nurses and a perhaps a technician, but some practices are very large. Would dentists be required to provide quality accounts? I think they fall into the bracket that the Minister was just describing.

Mike O'Brien: The straight answer to the question on dentists is yes, but not immediately. In the first year of quality accounts, acute hospital trusts will be required to provide a quality account, including ambulance and mental health trusts. In the second year, that will be extended to various community services, and in the third year, it will extend to primary care services such as GPs and dentists. We will work in detail with GPs to develop an approach that works for them. The national criteria for quality accounts that apply to acute hospitals will obviously not apply to a dentist, so we have to work with each of the stakeholders to ensure that we develop quality accounts that are suitable for that sector of the NHS.

Michael Penning: The Governments impact assessment on quality accounts and the Bill in general said that there would be an impact, a cost and a burden on those who provide a quality account. Does the Minister realise that if we bring in small organisations such as dentists, chiropodists and physiotherapists who are contracted into the NHS, the burden on those businessesespecially dentists, who tell me that it is driving them away from the NHSwill be so onerous that we may well lose even more of them than we lose at the moment?

Mike O'Brien: I thought the hon. Gentleman was supporting quality accounts. We will be looking at how quality accounts will have to be delivered by GPs and dentists. I assume that both of those types of organisations will want to measure the quality of what they do. I certainly hope that my dentist is concerned about the quality of his work. I hope that he wants to be sure that it is of a sufficiently high quality and that he checks the nature of the treatment delivered to patients. The difficulty is that, yes, there will be a need to write some of that down. Will it be an onerous or undue burden? In our view it will not. Will it enable the public to know what they get in return for the money that goes into NHS dentistry? It should provide them with more data and information. Will it enable them to have a better idea about what their GPs are doing, what their specialisms are and where they see the need for improvements in the coming year or two? Yes, it should; that is the sort of thing that we want GPs, dentists and others to do.

John Pugh: I am thinking about the public health agenda. A number of organisations are involved in partnership with the NHS in order to follow through on very important public health objectives. Many of them are quite small organisations working in fields such as alcohol awareness. Will they too be required to produce quality accounts?

Mike O'Brien: It depends on the nature of the organisations. What we have is the ability to take a view that we will not require quality accounts from particular organisations, because of the nature of the services they provide. Those organisations may have some NHS funding, but quality accounts would not be something that they need to do. We are looking in particular at some smaller organisationsor small practitioners, or providersand considering whether they need to provide quality accounts and, if so, the extent of the level of data they would need to provide. We have the ability in the Bill to exclude and take a view on those organisations. We are now in the process of consulting with various stakeholders about exactly how we can ensure that quality accounts will apply to their particular areas. There is the consultation, which will hopefully now proceed with broad support as the Bill goes through the House. In due course, because we are phasing this in over a number of years, we will want to consult with the various organisations to get this right and make sure the delivery of quality accounts does not produce an undue burden, not just for small practitioners, but also for the organisations described by the hon. Gentleman.

Michael Penning: I have listened carefully to the Minister. He is absolutely right in indicating that at the start of the Bill we were broadly in support of quality accounts. That does not mean that, after our probing amendments, we are not concerned about some of the comments that have been made in the debate this morning, not least because the Governments own impact assessment said:
There may be a lack of resource within organisations to prepare Quality Accounts - recruitment, on either a temporary or permanent basis may be required.
How does that tie up with the comments made by the Minister a moment ago that he does not think that quality accounts will be onerous for such bodies?

Mike O'Brien: Just to give the hon. Gentleman some estimate of the cost that we think that quality accounts might bring to an organisation, our impact assessment has calculated that it would cost around £3,000 per annum for the larger providersan acute hospital trust, for exampleto provide the data. That is the sort of calculation that we have put in it. As I indicated, we are open to exempting some of the smallest providersthose which may only see, for example, a handful of NHS patients in any one year.

Michael Penning: I have listened to what the Minister says. I do not think that dentists would fall into that bracket of only a handful and I can hear now, from a distance, the dentists being very concerned; they already are concerned about the provision of dentistry in the NHS.

The Chairman adjourned the Committee without Question put (Standing Order No. 88).

Adjourned till this day at One oclock.